Transcript

Norman Swan: Welcome to the program. Today, a special Health Report on a global problem which is getting worse and worse.

In a recent report Professor Paul Zimmet of the International Diabetes Institute in Melbourne estimated that there are around 100-million people worldwide with the two main forms of diabetes, but that is set to get much worse.

Paul Zimmet: Our report concluded that by the year 2010 AD there would be something like 230-million people worldwide with diabetes.

Norman Swan: More than a doubling in the next 10 or 15 years unless something is done about both juvenile or insulin-dependent diabetes, and more importantly, so-called adult onset or non-insulin-dependent diabetes. It's affecting huge numbers in every developed country, especially where there are indigenous people.

Anne Blair-Gould of Radio Nederlands has investigated this scourge and she prepared this feature. Here again is Professor Paul Zimmet of Monash University. The report he co-authored was called The Rising Global Burden of Diabetes and its Complications.

Paul Zimmet: The increase is mainly in people in developing countries and in the form of diabetes, non-insulin-dependent diabetes, which is a lifestyle-type disorder. What one is seeing that with changing lifestyle in the developing countries as they adopt a more western way of lifestyle - less exercise, more processed food with high fat content and low in fibre - there is this move to western-style diseases that weren't present before: heart disease, high blood pressure, obesity and non-insulin-dependent diabetes.

Anne Blair-Gould: In order to understand how lifestyle could affect the incidence of a disease, we need to understand what diabetes actually is. Now most people know that diabetes is something to do with blood sugar, and something called insulin. But what exactly is insulin and what does it do?

Well Professor Michiel Krans is an endocrinologist at the Academic Hospital in Leyden, here in the Netherlands, and he explains.

Michiel Krans: You need energy for the whole day. You eat only three or four or two times per day, but you need your energy the whole day. So as soon as you eat, your energy gets stored in fat and liver and muscle, and during periods that you are not eating, then the energy can free from liver and fat and muscle. And insulin is the hormone-rich stimulates the uptake of the energy you eat. So if you have insufficient insulin, then you get your energy into your bloodstream, but it doesn't go into your tissues, and that means that your blood glucose goes up and that's what you see when you have diabetes.

Anne Blair-Gould: Now at this point it's important to know that there are two types of diabetes. The first, previously known as insulin-dependent diabetes mellitus is probably the better known of the two types of diabetes, and nowadays it's called Type 1.

Michiel Krans: That's a diabetes which is caused by destruction of the islets of Langerhans and this destruction is a very complicated process. We call it so-called auto-immune process, which means for a certain reason, one of the islet cells is damaged, some product from the islet comes out and the body defends itself against these islets just like it does against bacteria when you get an infection. And these antibodies formed towards these products of the islets, destruct more islets and so finally all the islets are destructed.

Michiel Krans: Yes, that's right. The only thing is that it seems that you need some outside factor to get the destruction and there is also some genetic information available which makes you more or less liable to this type of destruction. So not everybody gets diabetes.

Anne Blair-Gould: Now Type 1 diabetes which accounts for about 10% of the cases in the world, is arguably the more severe form, partly because it begins early, often in childhood, allowing a much longer time for complications to develop. Once you develop Type 1 diabetes, you have to monitor your blood sugar and administer insulin throughout the day, every day, for the rest of your life.

Egelantine Otter is a dietitian at the Netherlands Diabetes Association and is herself a Type 1 diabetic. I asked her to take me through a typical day.

Egelantine Otter: I start with checking in the morning how high or low my blood sugar is, then I try to take the right amount of insulin, and then I start my day like you. When I get at my work, I check again my blood sugar.

Anne Blair-Gould: What does that involve, how do you take your blood sugar?

Egelantine Otter: I use a small needle, I put it in my finger and out comes a little blood, and I use a test drip that reacts with the glucose in the blood, so after a few seconds it shows how high or how low my blood sugar is.

Anne Blair-Gould: How many times a day do you have to do that?

Egelantine Otter: I must do it four times a day, before each meal and before I go to bed, and to check out if the right amount of insulin is taken for the amount of carbohydrates in my diet, I'll check it two hours after the meal again.

Anne Blair-Gould: Do you find that the values of your sugar vary tremendously?

Egelantine Otter: Yes. This weekend I had a bad weekend. I had very much lows, and very much highs because the high blood sugar levels are often a reaction to the low blood sugar levels.

Anne Blair-Gould: Do you know why that would be? I mean, were you out partying, or did you have a cold? What sort of things would affect whether it was high or low?

Egelantine Otter: There are a lot of things that affect blood sugar. This can be more physical activity, it can be using drinks with alcohol, eating a meal that's too fat so the carbohydrates will ingest your blood very slowly.

Anne Blair-Gould: When you've measured your blood sugar and it's too high, what do you then do about it?

Egelantine Otter: When it's too high I'll take a little insulin extra, and when it's too low I go and drink something that contains sugar.

Anne Blair-Gould: Having Type 1 diabetes is, as you hear, quite a responsibility and demands an organised schedule. But I asked Egelantine was it ever possible to indulge, just a little?

Egelantine Otter: I can eat everything I want, but not in the amount you would like and not at the times you probably would like. I have always to keep in mind can I use it at this moment?

Anne Blair-Gould: Give me an example, because it's easier to identify. Say for instance somebody in this building this afternoon had a birthday and it was cakes, big fat cakes out, you know, you presumably have to think about this you know, 'Oh, a nice big slice of chocolate cake, I'd really like that.' Would you be able to have it, or would you have to have a small amount, or how would you work that out in your head?

Egelantine Otter: When my blood sugar is OK, I will have a small amount, but that's more because I don't want to become very fat, and I first have to take my insulin, wait half an hour, and then you can eat it. And waiting that half hour is a problem, and it's looking at you from your desk.

Anne Blair-Gould: Temptations!

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Well whilst Type 1 diabetes is increasingly prevalent around the world, it's the other form of diabetes, Type 2 or non-insulin-dependent diabetes which accounts for 90% of cases of diabetes worldwide, and which is increasing every more rapidly. So what is Type 2 diabetes?

Professor Michiel Krans.

Michiel Krans: The 2 diabetes is very difficult disease. It has two components: one is insulin resistance which means that the insulin, which is exactly the same insulin as a normal person produces, has insufficient activity and the other part is that during this process you also get a decrease and a change in your secretion of insulin from the eyelets. So when you start to get Type 2 diabetes, you produce insulin often even more than a normal person does, but the action is not sufficient. So still your blood glucose goes up.

Anne Blair-Gould: Traditionally, Type 2 diabetes occurs in older people, usually after the age of 65, and that is one of the reasons why the incidence of diabetes globally is going up. There are more of us and we're living longer.

But what of other possible factors, like genetics for instance? Well genes do play a role, but that role is extremely difficult to unravel.

Michiel Krans: I always remember one of the sentences in one of the reviews saying, 'The genetics of diabetes is the geneticist's nightmare.' So it's very hard to say what exactly the genetics of diabetes. But we know that if one of your parents, or in the family of your parents, carries Type 2 diabetes, chances that you get Type 2 diabetes are much higher than when there is no diabetes in the family.

For Type 1, that's less clear. There's also a certain relation, so if you have diabetes and you get a child, the chance that your child gets diabetes is a little bit higher than when there is no diabetes, but it's only 1%, so it's very little. And the highest chance to get Type 1 diabetes is when you have a sister or a brother with diabetes. Then your chance is about 6% and sometimes, because Type 1 diabetes often starts in childhood, parents say, 'It's not fair, we do have already one child who's diabetic, and now we get a second one in the family.' But that's the way it happens.

Anne Blair-Gould: Well by now you're probably wondering what the early symptoms of diabetes are, and here there's often a problem, because the symptoms are somewhat vague, and people often put them down to other causes, ranging from stress through to old age.

So I asked Professor Krans what we should look out for.

Michiel Krans: It starts with you are more tired, sometimes you are starting to drink a little bit more, and you can't sleep for the whole night because you have to go to the toilet once or twice. You may also lose some weight, and those are the main complaints.

Anne Blair-Gould: And what physiologically is going on there, why those symptoms?

Michiel Krans: Well the most important thing is that since your insulin can't really handle your blood glucose because it's insufficiently effective, then you get insufficient energy in your muscle and in your organs, which means that you will lose weight and when your blood glucose really gets high, then your kidney starts to let the glucose slip through the kidneys and you get sugar in the urine.

Anne Blair-Gould: Well over the years, scientists have come to understand that as well as age, body weight plays a huge role in the development of diabetes, particularly Type 2, which is another reason for the global increase in cases. It seems we're all getting bigger and heavier. But how does a person's weight affect the amount of sugar in their blood?

Michiel Krans: If you are a heavy person, heavy for your length, then it often means that you carry more fat, and fat is one of the things which opposes the action of insulin. So if you have a lot of fat, then it counteracts the action of insulin. So there is some problem. And if you reduce your fat content, so if you lose weight, you will see that your insulin will act better, and you'll feel better and you'll need no extra things.

Anne Blair-Gould: Put bluntly, are fat people more likely to develop diabetes?

Michiel Krans: Sure. Yes. Fat people are certainly more likely to develop diabetes, and that's just simply because you need more insulin when you have a lot of fat to get the same blood glucose level.

Anne Blair-Gould: Now interesting work done both here in The Netherlands and elsewhere, suggests that not only is the amount of fat important, but also where that fat is.

Dr Edith Seskens is an epidemiologist at the Dutch Institute for Public Health and Hygiene in Bilthoven, here in Holland.

Edith Seskens: It has also something to do with the location of your body fat. If it's around your belly, it's much more dangerous, than if it's around your hips. So I think the women, like myself for example, who have more of the fat concentrated on the hips, that fat on the hips is less metabolically active, and it's only active in pregnancy and lactation. Whereas the male type of fat distribution with the belly, that type of fat is much more metabolically active, and actually quite more dangerous for the risk of developing diabetes.

Anne Blair-Gould: So what does that mean it's metabolically active, it sort of comes and goes more, or - ?

Edith Seskens: Yes, it comes and goes more, and if it comes and goes more, it's closer to the liver and this liver is very important for maintaining your blood sugar level on a certain level. So that's the main idea, it's closer to your liver and it's much more susceptible to all kinds of hormones, and in certain circumstances it therefore comes and goes more, which is more dangerous than a stable type fat depot around your hips.

Anne Blair-Gould: At this point it's clear that family history plays a role in whether or not a person develops diabetes, as does a person's age and body weight. But now new and intriguing research from the Academic Medical Centre in Amsterdam suggests that the state of your mother's diet whilst you were in the womb, may also play a role.

Dr Jan van der Meulen has recently looked closely at blood sugar levels of about 700 people who were born in and around Amsterdam at the end of the Second World War during an infamous period in Dutch history known as the hunger winter. At this time, food supplies to the soon-to-be-liberated Dutch living in the west of the country were cut off by the Germans and thousands of people starved to death. Well during this dreadful few months, people were surviving on very thin, but well documented rations of about 400 to 800 calories a day. And women pregnant at that time, understandably gave birth to low-weight babies. But what has this all got to do with diabetes? Dr Jan van der Meulen explains.

Jan van der Meulen: We found that people were born during the famine, who were born in the first few months of 1945, that they had a higher level of glucose in their blood as the people we took as controls, people who were born before or people who were conceived after the famine. So what we find is that being born during the famine, so having a mother whose diet was quite bad just before delivery, affects glucose metabolism and increases the risk of getting diabetes.

Anne Blair-Gould: Now this theory is a little provocative, but nevertheless very intriguing, so I asked Dr van der Meulen to explain very carefully exactly how the link between malnutrition in the womb and later development of diabetes would work.

Jan van der Meulen: What we think is that this is a kind of adjustment of the foetus, of the growing foetus. The foetus notices in a way that there's less food available, then there is some adjustment in growth, and these adjustments are such that the glucose metabolism is impaired to maintain growth as well as possible. And this adjustment in glucose metabolism may be permanent in a way, and may become apparent 30, 40, 50 years later.

Anne Blair-Gould: And the current huge increase in cases of diabetes fits in with this theory very nicely, according to Dr Jan van der Meulen. If a baby is born in a time of famine, its metabolic clock, so to speak, has already been set in the womb.

Jan van der Meulen: The problems arise when this environment changes. For instance, the foetus prepares itself for a life with a low intake of food, and problems arise when it experiences an affluent way of life, so I think there's something that has to do with change. Change during the course of life. And I think that's possibly also something that's behind the increase in the prevalence of diabetes in the world today, because what we see is that in a lot of societies the level of affluence is increasing very rapidly. So there is a generation now who have experienced a poor environment early in life; so before, or just after birth, is now living in an environment with an abundance of food, and this change during life might be something that's behind all these problems with glucose metabolism in the world today.

Anne Blair-Gould: Well let's go back to those worldwide problems as predicted in Professor Paul Zimmet's report. This estimates that diabetes will become two to three times more common in Africa and Asia in the very near future, and that Asia will likely be home to more than 60% of the world's diabetics by the year 2010. Again I asked do we have any idea why Asia will be so hard hit?

Paul Zimmet: The people from India have a particularly high susceptibility to diabetes and very high rates of diabetes are being seen in India, particularly in urban areas. The situation in China can be predicted by the fact for example that in Singapore alone, the prevalence of diabetes was something like 4% in 1984 and by 1992 it was over 8%. So it doubled in Singapore within less than a decade. The rates are already very high in Taiwan, Chinese in Hong Kong. So there is this pattern that of many parts of the world that one can look at that perhaps the problem is worst in Asia.

Anne Blair-Gould: Now over in Geneva in Switzerland the World Health Organisation's head office has also produced a global report on diabetes, which also predicts an enormous increase in diabetes around the world. Dr Hilary King, Head of the Division of Non-communicable Disease, is concerned not only by the numbers of cases, but other disturbing trends.

Hilary King: Well what worries me the worst perhaps, is that if we compare the developed and developing countries: in developed countries, this Type 2 diabetes is generally a disease of the elderly people of 65 years and over for example. But if we look at the figures for the developing countries, we see that the diabetes, the number of cases concentrates some 20 years earlier in the age group of between 45 and 64 years of age. And our predictions based upon the demographic changes that are known to be happening in the world, are that this will even accentuate in future.

So it means that in these developing countries, people get diabetes at the most productive time when they're supposed to be providing for their families, and also that they have many years longer to develop the serious complications of diabetes.

Anne Blair-Gould: Complications which include nerve degeneration, loss of sight, and kidney problems. Professor Paul Zimmet has also noted this trend, and worries about the further implications of this decreasing age of onset of diabetes Type 2.

Paul Zimmet: Diabetes has a huge socio-economic impact because not only the cost of treating people with diabetes, but the complications of diabetes can be blindness, can be kidney failure, can be damage to the nerves of the limbs resulting in amputation, so you have all the potential rehabilitation costs, the costs of dialysis, the costs of visual rehabilitation. Other complications of diabetes include heart disease and stroke. So you have all of those costs of associated disorders with the diabetes; and of course there are the social implications that in certain countries, people with diabetes prefer to remain in the closet and keep the condition quiet from their employers because it may affect employment and the type of jobs they can undertake.

Anne Blair-Gould: It's apparent that there is a stigma attached to having diabetes, and this business of perhaps losing a job is very real. In fact it happens all over the world. Emil van Berkel is spokesperson for the Dutch Diabetes Association, which has also detected a real rise in the number of cases of diabetics here in Holland, and which predicts a doubling of the total number of people with diabetes within the next decade.

Many people, he says, worry not only about the medical implications of having the disease, but also the socio-economic ones.

Emil van Berkel: Well let's say for instance, the insurance. There is a big chance they have to pay 100% to 500% more on their health insurance. It's very difficult to get a no-risk insurance for the same price as everybody else. So individual cases and in general, we try to help those people, by telling the Government That's not just to take those measures, and we tell the insurance companies the same story. And when the individuals need help, we help them. For instance, when you are a bus driver and you get your driver's licence, it could be very difficult to get it, in the first places, and when you have it, some employers are even firing you when they notice you have diabetes, and that's not just even against the law. So we try to help those people.

Anne Blair-Gould: What is the thinking, for instance, if you were a bus driver and then they threaten to take away your licence because you're diabetic, what was the thinking, do they think you're suddenly going to have a blackout in the middle of the traffic?

Emil van Berkel: It's possible when your blood sugar is too high or too low, you're not able to drive, right? But when you are taking good care of yourself, there's in effect, no greater problem than we have now with diabetes.

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Anne Blair-Gould: Now let's look a little at insulin. Discovered and first used to treat diabetes in 1920, insulin has been saving lives ever since. However there are still many problems with administering insulin. Firstly, you can't eat it, as it breaks down very rapidly, a long time before it reaches the blood stream. So it needs to be injected directly into the blood.

But Professor Michiel Krans foresees improvements in this system in the years to come.

Michiel Krans: One of the improvements I can see in the not too long future, could be an improvement of the injection system, not so much the injection system, besides pens which inject insulin, we have also pumps which deliver insulin continuously. All these pumps have to be regulated by the blood glucose levels. As long as we do not have a message to measure blood glucose continuously, you can't make a feedback system to the pumps. So if something like that could be technically appliable, but we are only working 30 years on it, so I hope it happens. But anyhow that I think should be an improvement for many of the patients.

Anne Blair-Gould: And there's much work being done worldwide on the possible transplant of islets of Langerhans. These are the groups of cells which produce insulin in the pancreas, just behind the stomach. However, results in human trials so far have been rather limited. But things have improved over the years since insulin was first discovered, at least in some parts of the world.

Professor Michiel Krans again.

Michiel Krans: In the older times, most of the insulin came from animals. It was exacted from the pancreases from animals from the slaughterhouse. So you had insulin, bovine insulin, coming from the cows, or insulin coming from the pigs. But the synthetic insulin we make now has exactly the same structure as the human insulin, and insulin from a pig differs a little bit from human insulin.

Anne Blair-Gould: So the insulin we inject is human insulin, it just happens to be made by bacteria?

Michiel Krans: Almost all the insulin. Although there is still animal insulin available. The process of producing animal insulin is cheaper than producing the synthetic insulin, so in developing countries we try to set up also the animal insulin, but after you've extracted that insulin from the animals, you still need a very elaborate way of purification, and that makes it also very expensive. So if you inject the crude extracts, then you have also other proteins which give all types of reactions, which is not good.

Anne Blair-Gould: And as if that statement wasn't alarming enough, this one from Professor Paul Zimmet is almost unbelievable.

Paul Zimmet: It's very distressing that for insulin-dependant diabetes and I mentioned earlier the need for insulin to keep people alive, that in many countries insulin isn't available and there are children and young adults dying because of the lack of insulin. Our institute is involved in a program which helps with the distribution of insulin to countries, Africa, Asia, even to Bosnia, where insulin supplies aren't available, it's a life-saving scheme, but of course it doesn't address the whole problem worldwide of insulin availability.

Anne Blair-Gould: And the International Diabetes Federation, based in Brussels in Belgium, sadly reports many cases of people and children drying, either because insulin was unavailable or simply it was too expensive.

Well in an effort to draw together some of this, we should at least take comfort from the fact that there are things we can do to decrease very substantially the risk of getting diabetes. And the most important of these is to keep the weight down. Scientists agree that obese people have a far greater risk of getting diabetes than people who are not overweight. And physical exercise also reduces the risk. And then, there's your diet.

Edith Seskens: If you use more of the animal type of fat and less the vegetable type of fat of the fish fatty acids, we believe you are at an increased risk of developing diabetes similar as for example developing high cholesterol levels. Whereas if you use more for example vegetables and fruit and more fibre-rich bread, that kind of stuff, we know that you reduce the risk of developing diabetes and you would use your blood sugar levels and especially fibre is very interesting because we see that also we advocated also for diabetic patients where the effect is so clear of the fibre-rich foods that even for diabetic patients it's very clear that they can reduce their blood sugar that way.

Anne Blair-Gould: But I'll give the final word today to Professor Paul Zimmet of the International Diabetes Institute in Melbourne. In amongst the gloomy predictions, does he see anything hopeful?

Paul Zimmet: There is some good news on the horizon. While we can't prevent the insulin-dependent form of diabetes at present, and there's a lot of research activity that leads one to believe that may be possible within the next five years or so, there are certainly ways of preventing the non-insulin-dependent, or lifestyle, form of diabetes. In many countries already there are programs being developed that encourage healthy lifestyle, a proper diet, weight reduction and a lot of physical activity, in order to prevent those at risk. So yes, there is a way of doing it, but that also depends very much on the behavioural changes and people being prepared to take those changes, and yes, we could do something to reverse this epidemic that's come.

Norman Swan: Paul Zimmet, who's Professor of Diabetes at Monash University in Melbourne. Anne Blair-Gould of Radio Nederlands made that special feature.

Guests

Professor Paul Zimmet

International Diabetes Institute,Melbourne

Professor Michiel Krans

Endocrinologist,Academic Hospital,Leyden, Netherlands

Egelantine Otter

Dietitian,Netherlands Diabetes Association

Dr. Edith Seskens

Epidemiologist,Dutch Institute for Public Health and Hygiene,Bilthoven, Holland

Dr. Jan van der Meulen

Academic Medical Centre,Amsterdam

Dr. Hilary King

Head of the Division of Non-Communicable Diseases,WHO,Geneva, Switzerland